MEDICARE: ACADIAN DIAGNOSTIC LABORATORIES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46D2114570	OTHER	UT	CLIA

General Provider Information

NPI Number	:	1891204160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACADIAN DIAGNOSTIC LABORATORIES LLC

Provider Business Mailing Address
First Line	:	11842 JUSTICE AVE
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-5324
Country	:	US
Telephone Number	:	225-448-5886
Fax Number	:	225-292-5956

Provider Business Practice Location Address
First Line	:	2500 S DECKER LAKE BLVD STE 4
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84119-5782
Country	:	US
Telephone Number	:	225-448-5886
Fax Number	:	225-292-5956

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	TERRY S WILKS JR.
Credential	:
Telephone Number	:	225-448-5886

Provider Enumeration Date	:	09/29/2017
Last Update Date	:	10/25/2019

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